GW1-2022-09734_Well Construction - GW1_20221027

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: T
I.Well Contractor Information: 14.Q \ -• s C�t.�� �-y TER ZONES
FROM I
_ FROM TO DFSCRIPTION �
Well ContractorNameD it 7 LIt, 5
NC Well Cont:actori Certification Number A] 1f I .L vim\ 15.OUTERCASING for multiense [%yells OR LINER fn llcable 1
1Q, VV�`�•+ l ��V 1' 1 FRO?YI TO ILDIAlt1�11'ER 1n. THICHI�FSS bfATERIAI.
Company Name 16.1NNER CASING ORTUBING tothermnl closed-loo
2.Well Constrpcdon Permit#: .' FRONT TO DIAAWrER THICKNEss h1AIERIAL
In.
IL .
Gist all applicable u+ell consrrvetlon permits p e.UIC Counn.,Slate,Variance,etc.)
ft.
It. El
ILsn.
3.Well Use('beck welluse):
17.SCREEN
Water Supply Well: FROM TO I DtA_MIETER SLOT 5[7E TffiCKNESS h1ATEttIAI
[]Agricultural ❑Mimic' bHe ft. -7 ft,
OGeothermal(Heating/Cooling Supply) eatdeatial Water Supply(single) fL it. In.
•Olndustrial/Cmtltnercial []Residential Water Supply(shared) IR.GROUT
❑Irri tiara ❑Wells>IOO,000 GPD FROM TO ZL4,TEIUAL EbrPLAcFmLyr riEMODB A,%IDULiT
Non-Water Supply Well: ft
ElMorutonrig , '' -- -[]Recovery_ - _ _ _ n•
•Injection-Well: ' ft. It.
❑Aquifer Recharge ; '. ❑Groundwater Remediatioa 1g.SAND/GRAVEL PACK i!a licabie
❑Aquifer Stortige and Recovery OSalinity Barrier prams TO ;tATErtu.r. ��srrl.neeM1tENTasErnoD
OAquiferTest ` ❑StormwatcrDrainage rL
OExpedmental Technology []Subsidence Control
OGeotheimal(Qlosed Loop) ❑Tracer 20.DRILLING LOG attach additional sbeets If neewa
iyl
FROM TO DESCIrII nON color hardy toiVmc r e: in eta
OGedt cirnal(Reating/CoolingReturn) ❑Other(explain under,421Remarks)
4.Date Well(s)-Completed: 0-/A-r'Vell EDH n
ft. tt.
Sa.Well Location: TL
R
!• Fncili /OwnerNaine FacilityMN(if applicable) It.
tI.•• ft _ •�ri� L�'^ '
022JOS,Lnglts Co1 � ��. �RSi ft. I,
Physical Addre55CIty,and Zip
21.REMARKS r^,r a�_r.•s r
t �cIT PaelIdenti6eaHao No.(PIIt) - l ro
. t Corm y '
n
5b.Latitude slid longitude jn degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllolig is sufficieat) 22.Ce cation:
35rQ1 01 N %*77./GI es] w
6.Is(are)the Well(s): ermnnent or. OTemporary
Signature o Certified Well Contractor Date
ev sr ming thlsjonrt.[hereby cer(Ify that the t,'ell(s)iiw(t em)constructed in accordance it
7.Is this a repair to an existing well: , OYes or 15A NCA C 01C.0100 or 15A NCAC 02C.0200 Well Constmcdon Standards and that a copy
Iftlris is a repair,f 11 out h'7o n iwll canravc on injamallon and erpla nature of file ojrhts record has been provided to the ts,ell owner.
repair ander N21' rark section or on the back ojthts jornr. 23.Site diagram or additional well details:
4 You may use the back of this page to provide additional well construction info
8.For.Gioprobe/DPT tir-Closed-Loop Geothermal Wells having the same (add'See Ovee in Remarks Box),You may also attach additional pages if necessary.
cohatructioo,only I.GW;l is n_eeda ludicate TOTALNUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.T tal well depth below land surface:_ � G (R') Submit this GW-1 within 30 days of well completion per the following:
For multiple ire! list all depdu!f dierenr(example-3©200'and 2Q100)
248. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level;below top of casing: ~ (n) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
ljxater level lr cbove'=-Wg,use"+-
r^ 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole d=meter: `�-r (tn-) Program,I636 MSC,Raleigh,NC 27699-1636
12.Well consRuction method: �V, � VS 24c.For Water Supply and Olpen-Loop Geothermal Return Wells:Copy to the
t (Le.auger,rotar l cable,direct push,etc.) county environmental health department of the county where installed
LFOR-NYATF,RISUPPLY WELLS ONLY: 24d.For Water Wells producine over 100 OUO GPD:Copy toDWR,CCPCUA
Permit Program,161 l MSC,Raleigh,gpm) 0 Method of testection type: ���1r�hS, Amount:
Form GW-1 North Carolina Department of Environmeotal Quality-Division of Water Resources Revised 6.6-2018